Sinusitis

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Sinuses are not fully developed until age 20 years. Maxillary and ethmoid sinuses, although small, are present from birth.
Because children have an average of six to eight colds per year, they are at risk for developing sinusitis.
Diagnosis can be more difficult than in adults because symptoms are often more subtle.

DIFFERENTIAL DIAGNOSIS

Dental disease
CF
Wegener granulomatosis
HIV infection
Kartagener syndrome
Neoplasm
Headache, tension, or migraine

DIAGNOSTIC TESTS & INTERPRETATION

Diagnostic tests are not routinely recommended; no diagnostic tests can adequately differentiate between viral and bacterial rhinosinusitis (2)[C].

None indicated in routine evaluation
Routine use of sinus radiography discouraged because of the following:
- ≥3 clinical findings have similar diagnostic accuracy as imaging.
- Imaging does not distinguish viral from bacterial etiology.
Limited coronal CT scan can be useful in recurrent infection or failure to respond to medical therapy.

Diagnostic Procedures/Other
Sinus CT if signs suggest extrasinus involvement or to evaluate chronic rhinosinusitis
Test Interpretation

Inflammation, edema, thickened mucosa
Impaired ciliary function
Metaplasia of ciliated columnar cells
Relative acidosis and hypoxia within sinuses
Polyps

TREATMENT

Most cases resolve with supportive care (treating pain, nasal symptoms). Antibiotics should be reserved for symptoms that persist >10 days, onset with severe symptoms (high fever, purulent nasal discharge, facial pain) for at least 3 to 4 consecutive days, or worsening signs/symptoms that were initially improving (1,2)[C].

GENERAL MEASURES

Hydration
Steam inhalation 20 to 30 minutes TID
Saline irrigation (Neti pot) or nose drops
Sleep with head of bed elevated.
Avoid exposure to cigarette smoke or fumes.
Avoid caffeine and alcohol.
Antibiotics are indicated only when findings suggest bacterial infection.
Analgesics, NSAIDs
Acute viral sinusitis is self-limiting; antibiotics should not be used.

MEDICATION

First Line

Decongestants
- Pseudoephedrine HCl
- Phenylephrine nasal spray (limited use)
- Oxymetazoline nasal spray (e.g., Afrin) (not to be used >3 days)
Analgesics
- Acetaminophen
- Aspirin
- NSAIDs
Antibiotics
- Antibiotics have a slight advantage over placebo at 7 to 14 days (3)[A], yet most improve without therapy.
- Reserve antibiotic use for patients with moderate to severe disease.
- Choice should be based on understanding of antibiotic resistance in the community.
- Infectious Disease Society of America recommends the following (1)[C]:
  - Start antibiotics as soon as clinical diagnosis of acute bacterial sinusitis is made.
  - Use amoxicillin-clavulanate rather than amoxicillin alone.
  - Amoxicillin-clavulanate 875/125 mg q12h; 2 g orally BID in geographic regions with high rates of resistant S. pneumoniae
  - Doxycycline: 100 mg PO BID an alternative to amoxicillin-clavulanate for initial therapy (adults only)
  - Trimethoprim-sulfamethoxazole (TMP/SMX) and 3rd generation cephalosporins not recommended due to high rate of resistance (1)[C]
  - Treat for 5 to 7 days in adults if uncomplicated bacterial rhinosinusitis (IDSA low-moderate-quality evidence). Treat for 10 to 14 days in children if uncomplicated bacterial rhinosinusitis (IDSA low-moderate-quality evidence).
- American Academy of Pediatrics recommends the following (1)[C]:
  - Amoxicillin: 45 to 90 mg/kg/day in 2 divided doses if uncomplicated acute bacterial sinusitis in children
  - Amoxicillin-clavulanate: 80 to 90 mg/6.4 mg/kg/day in 2 divided doses for children with severe illness, recent antibiotics, or attending daycare
  - Levofloxacin: 10 to 20 mg/kg/day max 750mg/day if history of type 1 hypersensitivity to PCN (1)[C]
  - Clindamycin (30 to 40 mg/kg/day) + cefixime (8mg/kg/day in 2 divided doses) or cefpodoxime (10 mg/kg/day in 2 divided doses) (1)[C] for non-type 1 PCN allergy
  - Ceftriaxone: 50 mg/kg IM single dose if not able to tolerate oral meds (4)[C]
Because allergies may be a predisposing factor, some patients may benefit from use of the following agents:
- Oral antihistamines
  - Loratadine (Claritin), fexofenadine (Allegra), cetirizine (Zyrtec), desloratadine (Clarinex), or levocetirizine (Xyzal)
  - Chlorpheniramine (Chlor-Trimeton)
  - Diphenhydramine (Benadryl)
- Leukotriene inhibitors (Singulair, Accolate), especially in patients with asthma
- Nasal steroids (i.e., fluticasone [Flonase])

Second Line

Levofloxacin (Levaquin): 750 mg/day for 5 days or moxifloxacin 400 mg/day for 5 to 7 days (adults only) (1)[C]
If no response to first-line therapy after 72 hours
- Broaden antibiotic coverage or switch to a different class, evaluate for resistant pathogens or other causes for treatment failure (i.e., noninfectious etiology) fluoroquinolones as above.
Note: Bacteriologic failure rates of up to 20-25% are possible with use of azithromycin and clarithromycin.
If lack of response to 3 weeks of antibiotics, consider the following:
- CT scan of sinuses
- Ear/nose/throat (ENT) referral

ISSUES FOR REFERRAL

Complications or failure of treatment
ALERT

Meta-analyses have demonstrated no benefit of newer antibiotics over amoxicillin or doxycycline.
Antibiotics recommendations vary with different guidelines. Patients seen by specialists are different from those in a primary care setting. Patients usually do not have complicated sinusitis in primary care setting.
- American Academy of Otolaryngology-Head and Neck Surgery Foundation (2)[C] recommends the following:
  - Consider watchful waiting without antibiotics in patients with uncomplicated mild illness (mild pain and temperature <101 °F) with assurance of follow-up within 7 days.
PCV-13 pneumococcal vaccine can be helpful in reducing chronic sinusitis in children (5)[B].
Use of intranasal steroids small but significant improvement in symptoms when used alone or in combination with antibiotics (6)[A].
Precautions
- Decongestants can exacerbate hypertension.
- Intranasal decongestants should be limited to 3 days to avoid rebound nasal congestion.

Pregnancy Considerations

Nasal irrigation with saline, pseudoephedrine, most antihistamines, and some nasal steroids are safe during pregnancy and lactation.
Antibiotics safe in pregnancy and lactation
- Amoxicillin, amoxicillin-clavulanate, cephalosporins
Antibiotic contraindicated: doxycycline, fluoroquinolones
Antibiotic safe in lactation but not pregnancy: levofloxacin

SURGERY/OTHER PROCEDURES

If medical therapy fails, consider sinus irrigation.
Functional endoscopic sinus surgery is the preferred treatment for medically recalcitrant cases.
Absolute surgical indications
- Massive nasal polyposis
- Acute complications: subperiosteal or orbital abscess, frontal soft tissue spread of infection
- Mucocele or mucopyocele
- Invasive or allergic fungal sinusitis
- Suspected obstructing tumor
- CSF rhinorrhea

INPATIENT CONSIDERATIONS

Hospitalization for complications (e.g., meningitis, orbital cellulitis or abscess, brain abscess)

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Return if no improvement after 72 hours or no resolution of symptoms after 10 days of antibiotics.

PATIENT EDUCATION

http://familydoctor.org/familydoctor/en.html
https://www.nlm.nih.gov/medlineplus/

PROGNOSIS

Alleviation of symptoms within 72 hours with complete resolution within 10 to 14 days

COMPLICATIONS

Serious complications are rare.
Meningitis, orbital cellulitis, brain abscess
Cavernous sinus thrombosis
Osteomyelitis, subdural empyema

REFERENCES

11 Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72-e112.22 Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl):S1-S39.33 Ahovuo-Saloranta A, Rautakorpi UM, Borisenko OV, et al. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev. 2014;(2):CD000243.44 Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-e280.55 Olarte L, Hulten KG, Lamberth L, et al. Impact of the 13-valent pneumococcal conjugate vaccine on chronic sinusitis associated with Streptococcus pneumoniae in children. Pediatr Infect Dis J. 2014;33(10):1033-1036.66 Hayward G, Heneghan C, Perera R, et al. Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis. Ann Fam Med. 2012;10(3):241-249.

ADDITIONAL READING

Aring AM, Chan MM. Acute rhinosinusitis in adults. Am Fam Physician. 2011;83(9):1057-1063.
Centers for Disease Control and Prevention. Get Smart: homepage. http://www.cdc.gov/getsmart/.
Williams JWJr, Aguilar C, Cornell J, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2003;(2):CD000243.
Wilson JF. In the clinic. Acute sinusitis. Annal Intern Med. 2010;153(5):ITC3-1-ITC3-15.

CODES

ICD10

J01.90 Acute sinusitis, unspecified
J01.00 Acute maxillary sinusitis, unspecified
J01.20 Acute ethmoidal sinusitis, unspecified
J32.9 Chronic sinusitis, unspecified
J32.8 Other chronic sinusitis
J32.4 Chronic pansinusitis
J32.3 Chronic sphenoidal sinusitis
J32.2 Chronic ethmoidal sinusitis
J32.1 Chronic frontal sinusitis
J32.0 Chronic maxillary sinusitis
J01.91 Acute recurrent sinusitis, unspecified
J01.81 Other acute recurrent sinusitis
J01.80 Other acute sinusitis
J01.41 Acute recurrent pansinusitis
J01.40 Acute pansinusitis, unspecified
J01.31 Acute recurrent sphenoidal sinusitis
J01.30 Acute sphenoidal sinusitis, unspecified
J01.21 Acute recurrent ethmoidal sinusitis
J01.10 Acute frontal sinusitis, unspecified
J01.01 Acute recurrent maxillary sinusitis
J01.11 Acute recurrent frontal sinusitis

ICD9

473.9 Unspecified sinusitis (chronic)
461.9 Acute sinusitis, unspecified
461.0 Acute maxillary sinusitis
461.2 Acute ethmoidal sinusitis
461.8 Other acute sinusitis
473.0 Chronic maxillary sinusitis
473.1 Chronic frontal sinusitis
473.2 Chronic ethmoidal sinusitis
473.3 Chronic sphenoidal sinusitis
473.8 Other chronic sinusitis
461.3 Acute sphenoidal sinusitis

SNOMED

36971009 Sinusitis (disorder)
15805002 Acute sinusitis (disorder)
68272006 Acute maxillary sinusitis (disorder)
67832005 Acute ethmoidal sinusitis
73237007 Chronic ethmoidal sinusitis
40055000 Chronic sinusitis (disorder)
38961000 Chronic sphenoidal sinusitis
35923002 Chronic maxillary sinusitis
77919000 Acute sphenoidal sinusitis
60130002 Chronic frontal sinusitis

CLINICAL PEARLS

When bacterial infection is present, patients recover somewhat more quickly with antibiotics, but the majority will recover with symptomatic treatment alone, and accurate diagnosis of bacterial sinusitis is very difficult.
Multiple meta-analyses have demonstrated no benefit of newer antibiotics over amoxicillin or doxycycline.
Overall NNT to prevent 1 persistent case at follow-up = 15; harm due to antibiotic-associated diarrhea is similar.
Significant patient symptom relief with nasal saline spray or drops or irrigation (Neti pot)

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